CFHR Appointment Request
Use this form to schedule an HIV or Hep C testing appointment.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What day and time works best for you?
*
Which tests are you interested in?
*
HIV
Hep C
HIV & Hep C
Submit
Should be Empty: